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Relief of pain and anxiety is a paramount concept in the provision of acute care pediatrics, and should be considered at all times. Many agents also have amnestic properties.
Conditions such as fracture reduction, laceration repair, burn care, sexual assault examinations, lumbar puncture, and diagnostic procedures such as CT and magnetic resonance imaging may all be performed more effectively and compassionately if effective sedation or analgesia is used.
The clinician should decide whether procedures will require sedation, analgesia, or both, and then choose agents accordingly.
Safe and effective sedation requires thorough knowledge of the selected agent and its side effects, as well as suitable monitoring devices, resuscitative medications, equipment, and personnel.
The decision to perform procedural sedation and analgesia (PSA) must be patient-oriented and tailored to specific procedural needs, while ensuring the child's safety throughout the procedure. In order to successfully complete this task, a thorough preprocedural assessment should be completed, including a directed history and physical examination. Risks, benefits, and limitations of the procedure should be discussed with the parent or guardian and informed; verbal consent must be obtained. PSA then proceeds as follows:
Choose the appropriate medication(s) and route. Commonly used medication classes include benzodiazepines (such as midazolam), opiates (fentanyl), barbiturates (pentobarbital), dissociative anesthetics (ketamine), and sedative-hypnotics (propofol).
Ensure appropriate NPO (nothing-by-mouth) status for 2–6 hours, depending on age and type of intake. For certain emergency procedures, suboptimal NPO status may be allowed, with attendant risks identified.
Establish vascular access as required.
Ensure that resuscitative equipment and personnel are readily available. Attach appropriate monitoring devices, as indicated.
Give the agent selected, with continuous monitoring for side effects. A dedicated observer, usually a nurse, should monitor the patient at all times. Respiratory effort, perfusion, and mental status should be assessed and documented serially.
Titrate the medication to achieve the desired sedation level. The ideal level depends on sedation goals and procedure type. PSA goals in the emergency department setting usually involve minimal or moderate sedation. Minimal sedation is a state in which the patient's sensorium is dulled, but he or she is still responsive to verbal stimuli. Moderate sedation is a depression of consciousness in which the child responds to tactile stimuli. In both cases, airway reflexes are preserved. It is important to remember that sedation is a continuum and the child may drift to deeper, unintended levels of sedation.
Continue monitoring the patient after the procedure has finished and the child has returned to baseline mental status. Once a painful stimulus has been corrected, mental status and respiratory drive can decrease.
Criteria for discharge include the child's ability to sit unassisted, take oral fluids, and answer verbal commands. A PSA discharge handout should be given, with precautions for close observation and avoidance of potentially dangerous activities.